Computer Vision Questionnaire

Please take a moment to complete this questionnaire.

Once completed, take it to your VSP doctor. Your doctor will then be more familiar with your work environment
and better able to determine if you are at risk of developing Computer Vision Syndrome, or if youll need special
computer glasses.

6. Do you wear contact lenses while working at the

General Information computer?
Yes No
1. Indicate time spent: (If yes, please wear them for your eye exam.)
On a computer at work: ____ hours per day
On a computer at home: ____ hours per day 7. Do you view reference material while working at the
On a handheld computer (e.g., Blackberry): computer?
____ hours per day
Yes No
(If yes, what percentage of time? _____)
2. Desktop or laptop computer Use: (circle applicable)
My work computer is a: desktop laptop In order for your VSP doctor to accurately assess your
My home computer is a: desktop laptop computer vision needs and possible appropriate eyewear,
the following must also be completed.
3. Lighting in work area: (please describe)
Overhead/desk: Distances/Direction
__________________________
Incandescent/ fluorescent: 8. Viewing distance (eye to computer screen) is
__________________________ __inches.

4. Are you experiencing any of the following symptoms 9. Viewing distance (eye to keyboard) is __ inches.
while at your computer monitor?
10. Viewing distance (eye to reference material) is
Check where appropriate
__ inches.
Headaches
Sore or tired eyes (eye strain) 11. The center of the computer screen is: (circle one)
Blurred near vision
above equal to below
Glare (light) sensitivity eye level eye level eye level
Blurred distant vision
If above or below, by how many inches? ____
Dry or watery eyes
Burning, itching, or red eyes (distant to near and back) 12. Reference material is: (circle one)
Back pain above equal to below
Neck and shoulder pain eye level eye level eye level
Double vision
If above or below, by how many inches? ____
5. Do you wear glasses while working at the computer?
Yes No
(If yes, please bring them with you to your eye exam.)

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